Health Information Management

Look for breakdowns in process and education to reduce modifier mistakes

JustCoding News: Inpatient, March 31, 2010

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Knowing whether a modifier is appropriate and if so, which to assign, is a challenging task. But an audit of incorrect modifier usage may unveil a number of other factors besides these that may cause inappropriate modifier assignment.

For example, in addition to coders in your HIM department, staff members from the following departments may have a hand in assigning modifiers:

  • Patient admission services
  • Charge entry
  • Patient financial services (PFS)

But as a result of either a lack of information or insufficient education, mistakes in modifier assignment tend to proliferate when non-HIM staff members are involved.

Ensure access to necessary information

To correct this problem, address the process surrounding the application of modifiers. If modifier assignment does not occur at the time of code assignment, determine how to communicate the necessary information among different departments involved to ensure that the appropriate modifier is applied on the claim, said Sheryl Spohn, RHIA, CHC, executive director of coding assurance, in the compliance department of WellStar Health System in Marietta, GA.

In some smaller facilities, staff members who work in patient admission services wear a lot of different hats and have a variety of responsibilities, said Spohn. In some cases they may actually be the ones placing the charges and potentially, the associated modifiers, she says.

In other facilities, ED patients, upon discharge, flow out through patient admission services where staff members conduct real-time charge entry to be able to identify total charges (e.g., the patient’s responsibility). So instead of the coders, these staff members may be responsible for choosing the appropriate charge and in turn need to be aware of which modifier(s) to assign, if any.

This is why education about assigning modifiers is important, not just for HIM and coding staff members but for staff members in other departments, said Spohn, who spoke during HCPro, Inc.’s February 23 audio conference, “Advanced Hospital-Based Modifier Clinic: Identify Risks and Ensure Accurate Reimbursement.”

“If the modifier is required on a code coming from the chargemaster, best practice includes communication back to the department level,” Spohn said. “Utilize a liaison in each department with whom you can communicate to determine what was actually ordered, how the service was changed or modified at the time that it was provided, and to determine whether or not a modifier actually needs to be applied to this particular service.”

Some providers make the mistake of relying on protocols that upon review don’t actually safeguard them from coding inaccuracies. For example, some providers have a protocol in the ED to do X, Y, and Z when a patient comes in with a certain diagnosis, said Sarah L. Goodman, MBA, CPC-H, CCP, FCS, president, CEO, and principal consultant of SLG, Inc., in Raleigh, NC. “But you really need to look at that patient’s specific medical necessity for a particular service, and only in that case would the modifier be appropriate,” she said.

Examine your processes and make sure that you get the required orders and documentation, and that this information is trickling down to the person who ultimately appends the modifier.

Incorporate coder review

Providers sometimes focus solely on the code assignment but then neglect to review the accuracy of modifier assignment, Goodman said. “You’re looking more at the code description and making sure the CPT code has been updated for the current year,” said Goodman, who also spoke during the audio conference. “But you may not be looking at all those little places where modifiers could be housed.”

Even when some things are hard-coded in your chargemaster or when some modifiers are appended at different places of service (e.g., patient access), when it gets to the HIM department, you’re going to want someone who has that basic knowledge and background or a credentialed coder at least reviewing the claim,” Goodman said.

Some hospitals have even modified their systems to allow HIM staff members to see all of the codes on a claim (e.g., radiology codes, rehab services, EKG services) and not just the surgery codes, Goodman said.

“Now it becomes more critical for individuals to see the big picture and see what else is on that claim before they choose a particular modifier,” Goodman said, explaining that there may be instances for which it’s not a problem having two surgery codes together. However it may be a problem having a particular surgery code reported with another service that performed the same day, she says.

Consider audits and reviews

To ensure compliance and accuracy in modifier assignment, consider the following strategies:

  • Internal monitoring: Identify how often modifiers are being applied across services and departments
  • External and internal auditing: Perform annual chargemaster or HIM coding validations
  • Process reviews: Identify where along the revenue cycle and claims process staff members could apply modifiers
  • Information technology (IT) system reviews: Understand the IT barriers to modifier application at the point of service
  • Education: Educate staff members in the service departments, in addition to those in your HIM/coding team

When performing internal audits for appropriate modifier usage, focus on finding trends, Spohn said.

“Look at overall usage of the code and then the percentage of usage with a particular modifier,” said Spohn, who suggests that you may want to examine usage of modifiers -59 or -25, for example. “If you follow the process through and understand where these modifiers are being applied, you’ll get a better sense of whether you need to provide the necessary education in those areas to be able to apply modifiers appropriately and consistently.”

Also, evaluate other behind-the-scenes elements, such as the chargemaster, Goodman said.

“Look at all the fields where modifiers might be held,” she said. “I’ve seen some instances, particularly in radiology, in which -RT modifiers to indicate right side are noted, however the -LT modifiers are not.”

In addition, avoid processes in which modifiers are applied without discrimination.

“Don’t hard code modifier -59,” Goodman stressed, adding that providers should try to move away from this practice.

Analyze processes and identify hidden culprits

When you apply modifiers after the claim has gone through the billing system and it’s hitting a claim scrubber and bouncing out at that time, it’s critical to remember that you need to come back to the patient financial system and apply the modifier there, Spohn said.

“Don’t simply adjust the modifier on the claim and let the claim go out the door because then the integrity of the data in the hospital information system has been compromised,” she said. “If you go to report later on the number of times that modifier -59 was applied, it’s not going to be accurate if it has being applied once the claim has left that billing system and gone out to a claim scrubber and you just modify it on the claim.”

Goodman also warns against the dangers of old habits, citing ones that she observed earlier in her career—specifically, letting post-its serve as policies for how to assign codes or modifiers.

“I was going to school and working in the PFS department at a local hospital, and at that time we used to have little post-it notes that said, ‘If you do this, then you do that,’” she said. “And now, we all know that this is a compliance risk for facilities and we have to be really careful that we go back to the documentation.”

If the documentation is not in the chart, then you can’t always append a particular modifier even if you normally would, or even if the code editor that you use suggests a certain modifier, Goodman said.

Look at your process flow, which can vary depending on your facility’s size, and determine what you can do to enhance communication among the different parties who may have a hand in reporting codes and appending modifiers. Also look for ways to improve the ability for different departments to capture the necessary information to report the appropriate modifiers.

“Is there ever a time when someone has to append a modifier at the time of billing? Is that modifier then getting back into the patient accounting system so that when you generate a claim for an auditor down the road, that they’re seeing the same thing that actually went out the door?” Goodman questioned. “If not, you’re going to have a claim released with a modifier, but no one is going to realize it went out that way because in the system where you go to regenerate it, it’s not going to be there.”

Editor’s note: To learn more about modifiers -25, -52, and -59 among others, purchase a copy of HCPro’s audio conference “Advanced Hospital-Based Modifier Clinic: Identify Risks and Ensure Accurate Reimbursement,” which was held on February 23.



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